HomeMy WebLinkAboutUST-APPL 8/26/2014UNDERGROUND STORAGE TANK
PERMIT APPLICATION
TO CONSTRUCT - INSTALL. NEW TANK (NEW FACILITY)/NEWS: FIRS T
TANK INSTALL (EXISTING FACILI'T'Y) /MOD -MINOR MOD ' f
Permit�� ®_
TYPE OF APPLICATION: ❑ NEW TANK INSTALL/NEW FACILITY ❑
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BAKERSFIELD FIRE DEPARTMENT
Prevention Services
1501 Truxtun Avenue, 1st Floor
Bakersfield, CA 93301
Phone: 661 - 326 -3979 • Fax: 661- 852 -2171
Page 1 of 1
NEW TANK INSTALVEXISTING FACILITY
MTNOR Mr)r)TFTrATTr)N OF FArT1 TTY
STARTING DATE/
PROPOSED COMPLETION DATE
FAQLrTy NmEr ce�
EXISTING FAQLiiy PERMIT #
FAQLITY ADDRESS Vb(D -
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CITY L®
ZIP CODEC, ® i
TYPE OF BUSINESS.
APN #
TANK OWNER •-- � CAS
PHONE #
ADDRESS v5t:)�
QTY ®,k
ZIP CODE �c) +
CONTRACTO ,
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CA LICENSE #
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ICC #
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ADDRESS
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23P CODE
X330
PmiONE # BAKE FIELD CITY BUSINESS LICENSE # WORKMANS COMP # INSURER \L�
-An BRIEFLY DESCRIBE THE WORK TO BE DONE: �r
WATER TO FAQLITY PROVIDED BY
;DEPTH TO GROUND WATER
SOIL TYPE EXPECTED AT SITE
of TANKS TO BE INSTALLED
s
ARE THEY FOR MOTOR FUEL?
YES ❑ NO
SPILL PREVENTION CONTROL AND COUNTERMEASURES PLAN ON FILE?
❑ YES ❑ NO
ITHIS,SECTION IS FOR STORAGE TANK IDENTIFICATION
VOLUME
UNLEADED
REGULAR
PREMIUM
DIESEL
OTHER
C> Q
0 ,D OD
Tank Testing Company
NAME OF TESTING COMPANY
PHONE NUMBER
MAILING ADDRESS
;NAME OF TESTER ®±
ICC*
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THE APPLICANT HAS RECEIVED, UNDERSTANDS, AND WILL COMPLY WITH THE ATTACHED CONDITIONS OF THIS
PERMIT AND ANY OTHER STATE, LOCAL, AND FEDERAL REGULATIONS. THIS FORM HAS BEEN COMPLETED UNDER
PENALTY OF PER7URY, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT.
NAME OF TESTER
ICC#
THIS APPLICATION BECOMES A PERMIT WHEN APPROVED
FOR OFFICIAL USE ONLY
!IboeAPPROVED:
APPROVED BY
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